Excretory urography

1. EXCRETORY UROGRAPHY FATIMA SHAH

2. urography Structure and function of urinary system. Ascending Urography - Retrograde/ Cystoscopic Descending Urography - Excretory/Intravenous

3. Excretory urography Timed series of radiographic images of urinary system after administration of IV contrast.

4. indications Suspected urinary tract pathology. Repeated infections -focus, damage Heamaturia Investigation of hypertension not controlled by medication in young adults. Renal colic. Trauma.

5. Contra-indications General contra indications to contrast agents. Diabetes, Thyrotoxicosis, Pregnancy Raised urea creat. urography unlikely to be successful. Metformin therapy

6. preparation Bowel prep.  Basic psychological preparation with reassurance & explanation of technique  Bladder emptied immediately before exam. Hx of Previous I.V.U. Previous experience of iodinated contrast media. Abdominal surgery, Allergies, drugs Hx.

7. Contrast media Ionic or HOCM eg urograffin used. Iodine is main element which imparts radio-opacity. 300mg I/kg body wt. 15-25 gm of iodine given. 20ml of 76% urograffin Greatest single predictor of contrast reaction is previous reaction to contrast

8. Adverse effects of cm MILD & TRANSIENT – NO Rx REQUIRED: -nausea,vomiting,sensation of heat, tingling, metallic taste,pain in arm,deire to urinate. ANTI-HISTAMINE & STEROID Rx: -Skin rashes;urticaria ,diffuse erythema. Angioneurotic edema,pruritis,sneezing&rhinorrhea ADRENALINE,AMINOPHYLLINE or SALBUTAMOL,O2 & STEROIDS Rx: -Broncho spasm and layryngeal edema particularly due to meglumine.

9. Routine procedure & filming sequence

10. Scout film Administration of contrast Early nephrogram Tomograms Excretory films

11. Compression banding: Aim to produce better PC distension C/I: Recent abd surgery. Renal trauma. Large abd mass. Obstruction. If 5min film shows adequate distension.

12. NEPHRogram PHASE End of Injection , A.P. of the renal areas to show the nephrogram, i.e. the renal parenchyma opacified by the contrast medium in the renal tubules.

13. Value of fluoroscopy. Fluoroscopic spot images demonstrate the entire luminal surface of the ureters.

14. On a radiograph obtained during bladder filling, the contrast material is smoothly defined and the bladder wall has become less evident. A normal uterine impression on the superior margin is noted

15. Post Micturition film to demonstrate the bladder emptying success, and the return of the previously distended lower ends of ureters to normal.

16. Analysis of ivu

17. Preliminary image Area: supra-renal - below symphysis. Assessment of Bones, stones, masses & gases. Oblique view helpful when pt symptomatic but no cause seen on KUB.

18. Urethral calculus in pt with hx of severe right flank pain.Collimated Radiograph shows calcification centered behind symphysis . CT helped confirm presence of urethral calculus.This case shows importance of full coverage of anatomic structures at KUB.

19. (a) Collimated preliminary radiograph of the pelvis shows no obvious stones

20. Rt post oblique radiograph of pelvis shows 6mm ureteral calculus now projected onto iliac bone.urogram (not shown)helped confirm rt ureteral obstruction 2ndry to the stone. This case shows how a calculus can be obscured by the complex sacral anatomy.

21. Preliminary image SKELETON: Evaluation of all bones. PSOAS MARGINS: -Straight: oblique &laterally -T12-illiac crest visualised if RP fat. -Convex: athletic musculature fluid in Psoas sheath. -Absent: scoliosis(one side) RP fluid or tumors

22. The plain KUB shows lumbar spondylosis with marked scoliosis and obvious asymmetrical thickness of the lateral abdominal wall musculatures. 

23. AP radiograph of pelvis shows parasymphyseal bone fragment along left pubis ,mild p. symphysis diastasis, &transverse fracture of rt transverse process .irregularity of rt SI joint space, suggestive of fracture.

24. Preliminary image from excretory urography demonstrates a looped configuration of the distal transverse colon and splenic flexure (arrows).

25. 50yrs female, known diabetic presented with lethargy, fever with chills and rigors. Urine examination shows multiple pus cells and ESR is elevatedabnormal gas in the left renal region

26. Another patient aged 45y r with similar history and marked suprapubic tendernessKUB radiograph showing air with in the bladder

27. Preliminary image KIDNEYS: visualised if peri-renal fat. GUT GASES: may over lap. Change in shape & location displaced by compression. CALCIFICATION OVER RENAL AREA: -True lat/ips-ilateral post oblique views. -Displacement with ins/exp/upright films.

28. Preliminary image EXTRA-RENAL CALCIFICATION: -Calcified Costal Cartilage, supra-RG. -Calcification in tail of pancreas, GB, liver, Splenic artery. -Phleboliths, chip fracture of TP.

29. On a scout image obtained before excretory urography, a calculus fills nearly the entirety of a bifid right renal collecting system, giving it a branched appearance that resembles the antlers of a stag.

30. Plain radiograph of the abdomen demonstrates extensive calcification in the left kidney, which was nonfunctional (the putty kidney), consistent with autonephrectomy from tuberculosis.

31. Preliminary image URETERS: not visualized. OPACITIES: -Intra-Luminal: ureteral stones. -Intra-mural: schistosomiasis . GAS SHADOWS: conform to shape of ureter. EXTRA-URETERAL CALCIFICATION: -mesenteric LN(mobile) - phleboliths , calcification in arteries.

32. Preliminary image U.BLADDER & URETHRA: - not visualised. - visualised if calculi or foreign body.

33. NEPHRogram PHASE Contrast in glomeruli & tubules.(1-3min) Four phases: SPONTANEOUS: Non-opacified, outlined by RP fat on plain film. VASCULAR: Opacification of intra-renal blood vessels. TOTAL BODY: “ of pre and retro renal soft tissue + vascular nephrogram INTRA-TUBULAR:” of intra-renal tubules.

34. NEPHRogram PHASE U=([P]xGFR)/Uvol a-extravasation of contrast b-absent blood flow : i-shock ii-no glomerular filteration : acute obstruction,infarction

35. Nephrogram phase Non- Visualisation : - Insufficient dose of contrast. - Acute, chronic renal disease - End stage renal disease. - Acute tubular obstruction - Ureteral calculus. - Renal agenesis - Renal artery thrombosis,avulsion .

36. NEPHROGENIC PHASE Size - Normal range-height of three vertebra. Enlarged kidneys suggest -polycystic disease -acute pyelo or glomerulonephritis Small kidneys imply chronic disease. Shape –Cysts & tumors may cause distortion. Orientation - disorientation may be -intrinsic, e.g. horseshoe kidney, or -extrinsic, i.e. pressure effect of other organs

37.   image of a tomographic sequence demonstrates symmetric nephrograms and pyelograms. Renal size is normal.

38.   On a 10-minute image, no pyelogram is evident. The nephrograms are persistent, and the kidneys are smaller. With this imaging sequence alteration, the patient should be evaluated immediately for the development of hypotension related to the procedure or as a reaction to contrast material administration.

39.   One-minute image shows slight asymmetry of the nephrographic opacity, with less opacity in the right kidney than in the left

40.   Image obtained at 80 minutes shows a persistent, very dense right nephrogram, a typical finding in acute high-grade obstruction. A 2-mm stone was discovered at the right ureterovesical junction.

41.   Enlarged kidneys in a young patient with early, asymmetric findings of autosomal dominant polycystic kidney disease. Nephrotomogram shows enlarged kidneys, the left more so than the right. Note the multiple parenchymal defects (“Swiss cheese” nephrogram).

42.   Right renal artery stenosis for evaluation of renovascular hypertension shows a small right kidney with decreased nephrographic density and temporal asymmetry of filling of the right collecting system compared with the left

43.   Fifteen-minute urographic image helps confirm the asymmetric renal size. Note the hyperconcentration of contrast material in the right collecting system compared with the left.

44. EXCRETORY PHASE Opacification of pelvicalceal system &bladder Filling defects include: stone,tcc,blood clots,papillary necrosis with sloughing of infarcted papilla. Strictures due to : -Post inflammation,previous stone impaction -Post infection,TB, Shistosomiasis -Cancer, intrinsic-tcc extrinsic-cevical ca

45. Tomogram from excretory urography demonstrates absence of the left kidney and deviation of the descending colon into the renal fossa.

46. EXCRETORY PHASE Common findings in bladder: -Filling defects , tumors -Trabeculated , thick walled bladder.

47. different patterns of excavation that can be seen with papillary necrosis: normal (A), central excavation with ball-on-tee appearance (B), forniceal excavation (C), lobster claw appearance (D), signet ring appearance (E), and sloughed papilla with clubbed calix (F) .

48.  Papillary necrosis. On an excretory urogram, contrast material fills central excavations (arrows) in the papilla of the interpolar region, Note the abnormal calices in the upper and lower poles as well.

49.  Papillary necrosis. Excavation extending from the caliceal fornices (arrows) produces the lobster claw deformity in another patient.

50. Delayed tomographic image from excretory urography shows caliceal crescents (arrowheads) surrounding the dilated collecting system. Contrast material pools dependently